Complaint Investigation Report

Regarding Allegation #1 : this investigation revealed that upon admission to the facility on 08/25/19, the physician’s report (dated 08/01/19) documented that Resident #1 (referred to as R1) had a history of skin condition/breakdown. Medical records (dated 08/26/19) noted a physical examination was performed on Resident #1 for pressure injuries present during hospital admission: right toe – Stage 2; Right heel – Stage 3 without surrounding erythema or purulence; severe Sepsis with acute organ dysfunction, non-traumatic acute kidney injury, BPH with urinary retention, Dementia, severe protein calorie malnutrition, venous statis edema with ulcer. Home health agency records (dated 08/26/19) documented that Resident #1 was referred to ComCare Home Health (an affiliate of Kaiser Permanente Medical Group) and was first seen by one of the on-site home health agency nurses on 08/29/19 for start of care. Home Health RN noted multiple wound locations: Unstageable pressure injuries on the left and right buttock/ open-skin injury on right toe, and open Stage 2 pressure injury on right heel. All wounds were reported to physician and coordinated to facility staff. ComCare Home Health Skilled Nurse (Florence Atena) instructed PCG’s in pressure management and prevention; of which, facility staff verbalized understanding. Medical records (dated 09/28/19) revealed that Resident #1 was hospitalized due to severe sepsis and was discharged back to the facility on 10/03/19. Resident #1 had wounds on: left heel – unstageable pressure injury; right heel – open Stage 2 pressure injury, measuring 3x3x0cm; right great toe – open skin injury, measuring 1x0.5x0cm; left buttock – unstageable . ComCare Home Health received the order (dated 10/04/19) to resume home health care to Resident #1. Staff #1 told ComCare Home Health Skilled Nurse, Florence Atena (on 10/11/19) that he had performed wound care on Resident #1’s sacrococcyx and did not allow Skilled Nurse Atena to turn Resident #1 (again) to check the wound. Skilled Nurse Atena documented and reported Resident #1’s health and behavioral condition. Based on Skilled Nurse Atena’s observations, it was believed that Resident #1 required a higher level of care. Skilled Nurse Atena continued daily wound care visits for Resident #1 and foley catheter change on 10/16/19. On 10/23/19, upon re-cert visit, Home Health RN, noted an unstageable pressure ulcer on Resident #1’s left hip and reported to medical doctor about the new wounds and recommended wound care treatment. On 11/06/19, Resident #1 was hospitalized due to a septic shock, dehydration, and pressure injuries. Resident #1 expired on 12/04/19. Based on evidence gathered and interviews conducted and records reviewed, the preponderance of evidence standard has not been met; therefore, the allegation NEGLECT/LACK OF SUPERVISION: Severe neglect resulting in resident developing a pressure injury is found to be SUBSTANTIATED.